Disclosures Atrial Flutter: Optimal Management Major Strategies - PDF document

◆ 12/17/16 Disclosures Atrial Flutter: Optimal Management ◆ Major Strategies in 2016 ◆ Research grant: R01 HL102090 (NIH / NHLBI) ◆ Research grant: R01 HL126555 (NIH / NHLBI) ◆ Research grant: DP14-1403 (CDC) ◆ Research grant: R24 A1067039 (NIH) 17 December 2016 33 rd Annual Advances in Heart Disease Park Central Hotel, San Francisco Zian H. Tseng, M.D., M.A.S. Murray Davis Endowed Professor Associate Professor of Medicine in Residence Cardiac Electrophysiology Section University of California, San Francisco Classification Outline ■ Classification & ECG features ■ Mechanism ◆ Macro-reentrant atrial circuit around a non- ■ Etiology, risk factors, epidemiology conducting obstacle, anatomical or electrophysiologic (scar) ■ Treatment Typical ■ ◆ Rate control ◆ circuit traverses the cavo-tricuspid isthmus (CTI: between IVC and TV annulus) ◆ Reversion to NSR ◆ CCW >> CW (“reverse”) ◆ Maintenance of NSR ■ Atypical ◆ CTI not involved ◆ Prevention of thromboembolism ◆ CHD, atriotomy scar, ASD, incomplete RFCA lines after PVI Lee G et al. Lancet 2012; 380, 9852 ◆ 1

◆ 12/17/16 ECG Features ECG Features ■ 2:1 AV conduction most common ◆ Even A:V rate ratios (2:1 or 4:1) > odd ratios (3:1 or 5:1) ■ 1:1 in high catechol states ■ 1:1 on class IC AAD without AVN blocker Sawtooth atrial pattern Atrial rate ~300 bpm, cycle length perfectly regular RR interval can help ECG Features Typical Atrial Flutter ■ 1:1 with accessory pathway (WPW) P wave rate ~300 bpm CCW - P waves II, ■ III, aVF + P waves ■ V 1 CW + P waves II, ■ III, aVF - P waves V 1 Cosio F et al. Rev Esp Cardiol. 2006;59:816-31 ■ ◆ 2

◆ 12/17/16 Typical CCW Atrial Flutter Atypical Atrial Flutter Bun SS et al. Eur H J (2015) 36, 2356–2363 Lee G et al. Lancet 2012; 380, 9852 ECG Features ECG Features ◆ 3

◆ 12/17/16 Epidemiology Epidemiology ■ Incidence ■ As with AF, highest with underlying heart disease, LAE, or RV/LV ◆ 181 AFL over 4 y in population based dysfunction study of 58,000 adults ■ 16% HF ✦ 5 per 100,000 p-y < age 50 ■ 12% COPD ✦ 587 per 100,000 p-y > age 80 ■ 1.7% (3 of 181) Normal heart/”lone” ◆ 2.5 x higher in men ■ 8% lone AFL in children and young adults ◆ ~200,000 AFL in U.S. per year ■ Rare after MI ■ Rare in digoxin toxicity Grenada J, et al. JACC 2000;36(7):2242 Grenada J, et al. JACC 2000;36(7):2242 Garson A, et al. JACC 1985;6(4):871 Garson A, et al. JACC 1985;6(4):871 Epidemiology Complications } ■ Risk factors ■ Ischemia ◆ After AAD for AF: ~15% in pts on class IC (flecainide ■ pre/syncope rate control or propafenone) ◆ Similar to those for AFib ■ HF ✦ thyrotoxicosis ✦ obesity ■ Thromboembolism/CVA ✦ OSA ✦ SSS ■ Tachycardia induced CM ✦ pericarditis ✦ COPD ■ rate + rhythm control ✦ PE ◆ After cardiac surgery: typical or atypical ◆ After AFib ablation: Atypical circuits created by ablation scars, amenable to ablation Grenada J, et al. JACC 2000;36(7):2242 Garson A, et al. JACC 1985;6(4):871 ◆ 4

◆ 12/17/16 Treatment Objectives Rate Control ■ More difficult than for AF ■ Ventricular rate control ◆ “stuck” at 2:1 ■ Reversion to NSR ■ Non-dihydropyridine Ca 2+ CB or ßB ■ Maintenance of NSR ■ Digoxin rarely used ■ Prevention of thromboembolism/CVA ◆ Mechanism: ^ vagal tone ◆ HF: dig + ßB ■ IV Amiodarone in acutely ill ■ AVJ ablation rarely indicated Reversion to NSR Ablation of Typical Atrial Flutter ■ RFCA may be considered first line ◆ Exception for AFL w/ reversible triggers: PNA, hyperthyroid, etc. ◆ ~92-97% success for typical AFL ◆ Often more sx than AF, ^ ßB needed ■ AAD vs. RFCA ◆ 61 pts ≥ 2 episodes of sx AFL within 4 mo period, mean F/U 21 months ◆ NSR: 80% RFCA vs. 36% AAD, p<0.01 ◆ Rehosp: 22% RFCA vs. 63% AAD, p<0.01 ◆ AF: 29% RFCA vs 53% AAD, p < 0.05 ◆ QOL improvement with RFCA but not AAD Lee G et al. Lancet Spector P et al. AJC 2009;104(5):671. 2012; 380, 9852 Natale A, et al. JACC 2000;35(7):1898 ◆ 5

◆ 12/17/16 Typical Atrial Flutter Atypical Atrial Flutter P wave rate ~300 bpm CCW - P waves II, ■ III, aVF + P waves ■ V 1 CW + P waves II, ■ III, aVF - P waves V 1 Cosio F et al. Rev Esp Cardiol. 2006;59:816-31 ■ Lee G et al. Lancet 2012; 380, 9852 Ablation of Atypical Atrial Flutter Atypical AFL Masquerading as Typical AFL ◆ RFCA success is lower, may not be considered firstline ◆ Tertiary care center w /high volume experience Bun SS et al. Eur H J ◆ High recurrence of other atypical AFL and AF (2015) 36, 2356–2363 Lee G et al. Lancet 2012; 380, 9852 ◆ 6

◆ 12/17/16 Reversion to NSR Atypical AFL after PVI ■ If no RFCA, DCCV >> AAD ■ Only IV ibutilide labeled for acute conversion ◆ 60% success, can also potentiate DCCV ◆ Confirm K + > 4.0, Mg 2+ > 2.0 ◆ Continuous monitoring for TdeP 4h (up to 8% risk) ■ If preexcitation (WPW): ◆ IV Ibutilide (III) or procainamide (IA) ■ AOD pacing ◆ PPM in place ◆ Post CTS with epicardial wires in place ■ AC or TEE if >24-48h or unknown Bun SS et al. Eur H J Spector P et al. AJC 2009;104(5):671. (2015) 36, 2356–2363 Natale A, et al. JACC 2000;35(7):1898 Maintenance of NSR Prevention of Thromboembolism/CVA ■ Identical to Afib ■ AFL recurrence after CV ◆ Embolic risk similar ◆ 50 pts after CV, no AAD ✦ 47% (6m), 58% (5y) ◆ 100 pts after CV for chronic AFL (6 mo) ◆ Lone AFL: Up to 75% recurrence ✦ CVA rate: 6% on AC vs. 0% no AC (p=0.02) ■ AFib recurrence after AFL RFCA: 7 – 82% ◆ Many also have Afib ◆ If AFib before: 36% ■ CHA 2 DS 2 -VASc ◆ If no AFib before: 13% ◆ ≥ 2 pts: AC ◆ Higher risk if LA > 4.0cm • Male (0 pt); Female (1 pt) ■ Careful monitoring before stopping AC • ≤ 64 yo (0 pt) • 65 to 74 yo(1 pt) ■ Consider PVI + AFL RFCA or CV + AAD if Afib • ≥ 75 yo (2 pts) found • CHF (1 pt) • HTN (1 pt) ■ AAD to suppress initiating PACs • DM (1 pt) ◆ IA, IC, ßB, amiodarone, dofetilide • H/o of CVA, TIA, or thromboembolism (2 pts) Crijns HJ, et al. Heart 1997;77(1):56. • Vascular disease (h/o MI, PAD, or aortic atherosclerosis) (1 pt) Halligan SC , et al. Ann IM 2004;140(4):265 Lanzarotti CJ, et al. JACC 1997;30(6):1506 ◆ 7

◆ 12/17/16 Prevention of Thromboembolism/CVA Take Home Points ■ Warfarin goal INR 2.0 to 3.0 ■ AFL is a macroreentrant circuit ■ NOACs: only Apixiban enrolled AFL pts ◆ Identical FL waves on ECG ■ All NOACs likely similar (dabigatran [bid], ◆ Typical CCW pattern most common rivaroxaban [qd], apixiban [bid], ◆ - P waves II, III, aVF ◆ + P waves V 1 edoxaban[qd]) ■ AFL Incidence and RFs parallel Afib ■ For Lone AFL (no triggers, CHA 2 DS 2 -VASc 0-1) ◆ Up to 100X more common in > 80 yo ◆ 1 mo before CV or RFCA if no TEE ◆ More common in men ◆ 1 mo after CV or RFCA ◆ CHF, LAE, COPD, thyrotoxicosis, post CTS ■ For CHA 2 DS 2 -VASc ≥ 2 ◆ post PVI for AFib ◆ AC unless contraindicated ◆ If considering stopping AC after 1 mo, careful close monitoring for AFib (long-term monitor or Linq) Take Home Points Take Home Points ■ Rate control ■ Maintenance of NSR ◆ AFL recurrence after CV high ◆ Non-dihydropyridine Ca 2+ CB or ßB ◆ Careful monitoring before stopping AC ◆ IV Amiodarone in acutely ill ◆ Search for evidence of prior AFib ■ Reversion to NSR ◆ Consider PVI + AFL RFCA or CV + AAD if Afib found ◆ AAD: IA, IC, ßB, amiodarone, dofetilide ◆ RFCA may be considered first line for typical AFL ■ Prevention of TE/CVA ◆ RFCA is a good option for atypical AFL at high vol centers ◆ Identical to Afib ◆ CHA 2 DS 2 -VASc: ≥ 2 pts use AC ◆ CV if acutely ill or not RFCA candidate ◆ Warfarin goal INR 2.0 to 3.0 or NOACs if renal ◆ Consider IV ibutilide if anesthesia is a concern function allows ◆ AC or TEE if >24-48h or unknown ◆ If considering stopping AC, careful close monitoring for Afib ◆ 8

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